PPO II - EmblemHealth

52 2011 Evidence of Coverage for 2013 HMO Evidence Medicare of Coverage Supplement for PPO (cost) II
Chapter 4: Medical Benefi ts Chart (what is covered Medical and what Benefi you ts Chart pay)
Services that are covered for you
Bone mass measurement
For qualifi ed individuals (generally, this means people at risk of losing
bone mass or at risk of osteoporosis), the following services are covered
every 24 months or more frequently if medically necessary: procedures
to identify bone mass, detect bone loss, or determine bone quality,
including a physician’s interpretation of the results.
Breast cancer screening (mammograms)
Covered services include:
• One baseline mammogram between the ages of 35 and 39
• One screening mammogram every 12 months for women age 40 and
older
• Clinical breast exams once every 24 months
Cardiac rehabilitation services
* Prior Authorization is required after the fi rst visit.
Comprehensive programs of cardiac rehabilitation services that include
exercise, education, and counseling are covered for members who meet
certain conditions with a doctor’s order. Th e plan also covers intensive
cardiac rehabilitation programs that are typically more rigorous or more
intense than cardiac rehabilitation programs.
What you must
pay when you get
these services
In Network:
$0 copayment for
each Medicare-covered
service
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
service
In Network:
$0 copayment for
each Medicare-covered
service
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
service
If you reside in New
York, Queens, Kings,
Richmond, Bronx,
Westchester, Rockland
and Nassau, you pay:
In Network:
$30 copayment for
each Medicare-covered
service
If you reside in
Suff olk, you pay:
In Network:
$25 copayment for
each Medicare-covered
service